Government of Ontario: Ministry of Health and Long-Term Care
Assistive Devices Program

Insulin Syringes for Seniors Program Application

The collection of the information on this form is authorized under the Ministry of Health Act, R.S.O. 1990, c.M.26, section 6(1)(4) to determine eligibility for assistance under the Assistive Devices Program. For further details concerning this collection, please contact the Senior Program Coordinator, Assistive Devices Program, 7th Floor, 5700 Yonge Street, Toronto M2M 4K5, telephone (416) 327-8804, 1-800-268-6021, facsimile (416) 327-8192.

Program Description

The Insulin Syringes for Seniors Program is intended to assist diabetic seniors, 65 years or older, to purchase needles and syringes for insulin administration.

Eligibility Requirements

Applicants must have a valid Health Card and require insulin injections on a daily basis. If you have recently turned 65 and are not registered with the Ontario Drug Benefit (ODB) Program or you are over 65 but have just started taking insulin injections, you should ask your pharmacist to give you a note indicating you take insulin injections. Send the note with the completed application.
The Program does not cover the cost of needles and syringes for residents of chronic care hospitals or persons who reside in Long Term Care facilities. These persons are provided with needles and syringes during their stay in these facilities.
Persons who reside in other residential facilities such as Retirement Homes or Private Boarding Homes are eligible to receive the grant.
Once your first application has been approved, Assistive Devices Program (ADP) will automatically send you a payment every 12 months.
ADP has the ability to confirm with the Ontario Health Insurance Plan (OHIP) that you are still a resident of Ontario and that your Health Number is valid. If something does not match the health card database, your payment will not be made. Therefore, if you change your surname or address, it is extremely important that you notify ADP immediately, in writing, at the address below. Also, if you receive a new Health card, call ADP with your new number.

Instructions

Please print all of the required information in the places indicated. Incomplete applications cannot be processed. It is an offence to knowingly provide incorrection information on this form. Facsimile or photocopies of this form are not acceptable.

Once complete, mail your application to:
Assistive Devices Program
7th floor, 5700 Yonge Street
Toronto ON M2M 4K5

Telephone: 416 327-8804 (Toronto), 1 800 268-6021 (Toll-free), or 1 800 387-5559 (TDD) if you have any questions about the Insulin Syringes for Seniors Program.

Applicant Information

Last name
First name
Middle initials
Date of birth
day
month
year
Health number
Version code
Address
City/town village
Apt. no.
Postal code
Area code
Telephone number

I certify that I am 65 years or older and that I use one or more injections of insulin daily. I certify that I am not a resident of a chronic care facility, nursing home or home for the aged. I certify that the above information is true, correct and complete to the best of my knowledge. I confirm that I am not eligible for financial assistance through the Department of Veterans Affairs (DVA), Group A or the Workplace Safety & Insurance Board (WSIB). I authorize the release of information collected under sections 4, 10, 11, 17, 29 and 45 of the Health Insurance Act R.S.O. 1990, c.H.6 in order to verify that I am eligible for health coverage. I authorize the release of information collected under section 5 of the Ontario Drug Benefit Act, R.S.O. 1990, c.O.10 in order to verify that I use insulin.

Applicant's signature
Date
day
month
year

1429-67 (2009/10) © Queen’s Printer for Ontario, 2009

Version française disponible